Cultural Differences Affect Nursing Practice

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By Jennifer Larson, NurseZone feature writer

Imagine this situation:

You are a women’s health nurse practitioner working in a clinic in a university town in a Southeastern state. A new faculty member asks you to help care for his pregnant wife, who has just moved to the United States.

That doesn’t sound so hard, or does it?

What if the woman were very young, recently married, Muslim, from Egypt and spoke almost no English?

That’s the situation that Linda Scott, RN, DNS, CFNP, found herself in last January. She turned what could be considered a difficult situation into an opportunity to learn how to provide culturally sensitive care, a topic receiving increasing attention in health care circles.

Now an assistant professor at Florida Atlantic University’s School of Nursing in Port St. Lucie, Florida, Scott was then working in Tuscaloosa, Alabama. She did not speak Arabic, and the nuances of appropriate care for a pregnant Muslim woman were unfamiliar.

“It was brand new to me,” she said. “It was a learning curve, every bit of it.”

But Scott did her research and found a good interpreter.

“I started asking around if anybody knew anything about Muslim culture. Then we went to the literature,” she said. “Bit by bit, piece by piece, we figured out what to do.”

Scott learned to incorporate many aspects of the couple’s Muslim faith into the prenatal, intrapartal and postpartal care. For example, Muslim women are extremely modest, and Muslim families expect respect for that modesty and often ask for a woman to always be present during examinations.

Scott also learned that the Muslim faith considers the left hand unclean, so she and the patient’s physician had to remember to touch the woman’s abdomen with their right hands.

Scott and Marietta Stanton, RN, PhD, coordinator of the Capstone College of Nursing’s graduate program at the University of Alabama, found the case educational enough to create a case study on providing culturally sensitive prenatal care to a pregnant Muslim woman to help enhance cultural awareness in nursing practice.

Interested in Learning More About Cultural Sensitivity in Health Care?

Resources include the National Center for Cultural Competence at Georgetown University, the federal Indian Health Service, or DiversityRx. Try the Transcultural Education Center, based in McLean, Virginia, or Transcultural Nursing, a Web site operated by a husband and wife team of nurses who have provided care to Hispanic and Haitian people.

Also, many nursing schools are beginning to incorporate cultural sensitivity into their mission statements and curriculum.

The University of Mississippi School of Nursing, offers a course titled "Exploration in Culture," and the University of Miami School of Nursing is working on a program called Holistic University of Miami at Agape Nursing (HUMAN) to provide culturally sensitive primary care in medically underserved communities. The University of Texas Health Science Center at San Antonio-School of Nursing, offered a class called "Hispanic Health Concerns: A Nursing Perspective" during the Summer 2001 semester.

Or visit your own nursing school's Web site to see what's offered.

Additionally, the nursing honor society Sigma Theta Tau has set a goal of increasing diversity within its membership. Visit the society's Web site for more infomration on cultural diversity.“Nursing is comprehensive,” Scott said. “We look at the person as an individual and all aspects of [her] life. You have to individualize [care] to meet their needs, according to their culture and their finances.”

The practice of respecting a person’s cultural situation when providing health care is attracting more consideration today, but many health care professionals say there is still not enough education about the need for such care.

The United States grows more diverse by the day. The U.S. Census Bureau showed a rise in the number of Hispanic people of 13 million from 1990-2000, and other ethnic populations are also growing.

“Because we live in a pluralistic society, however, many variations of health beliefs and practices exist,” wrote Rachel E. Spector in Cultural Diversity in Health and Illness (5th edition).

While Scott dedicated herself to researching her patient’s culture, many other health practitioners may just throw their hands up in defeat when confronted with a patient who might seem noncompliant or difficult to understand.

Prejudice is certainly a factor, according to Spector, who wrote that it occurs primarily when one person doesn’t understand another person’s heritage or generalizes about an entire culture.

Gihan ElGindy, RN, MSN, executive director of the Transcultural Education Center in McLean, Virginia, agreed there is a need for better cultural understanding. Health care professionals need to learn about their patients’ cultures and what is considered appropriate care, and communication is a vital component of that, she said.

“The expectation here is when your feet hit the United States, you have to know everything,” said ElGindy, who was born in Egypt and has practiced nursing on three continents.

Many people in the United States are not American, and their health care decisions, made with respect to their cultural beliefs, should be respected, she added.

What’s more, she believes health care professionals should seek out information on other cultures beyond textbooks.

ElGindy suggested a nursing student seek out a Hispanic clinic for a clinical rotation, to learn how to be an effective nurse around non-English speakers.

Scott recommended that health care professionals examine their regular patient loads to see what cultures they might learn more about.

“Those that you see on a regular basis, those are the ones that you would know the most about,” she said.

Laura Williams, MD, director of the Association of American Indian Physicians Ford Foundation Program and a faculty member at San Diego State University School of Public Health, agreed that health care professionals should learn about an ethnic group particularly if there’s a concentration in that population in their area.

Medical education is in even greater need of cultural awareness training than nursing, she added.

“Nurses are ahead of the game” compared to doctors, said Williams, who uses a textbook on cultural sensitivity written by a nurse.

But there’s still a need for more education because so many cultural misconceptions exist, she said.

Communication discrepancies can be a major factor, too.

“Language differences are possibly the most important obstacle to providing multicultural health care because they affect all stages of the client-caregiver relationship,” Spector wrote. “Communication differences present themselves in many ways, including language differences, verbal and nonverbal behaviors, and silence.”

Knowing she could not provide adequate care to her pregnant Egyptian patient because of the language and cultural barriers, Scott sought an Arabic translator. But even people who speak the same language don’t necessarily mean the same thing when they use similar words.

“Just because people speak English doesn’t mean there aren’t these cultural differences,” Williams said.

Over 60 percent of Native Americans speak English, but a wide range of cultural and tribal differences exist beneath the common language. Getting a good patient history can be challenging, said Williams, who is herself a member of the Juaneno-Achachemen tribe, because some Native Americans respond much better to indirect questions, rather than direct questions that seem overly probing.

“It’s more like storytelling, and it often takes longer to get the information out of the patient,” she said. “So it’s a matter of knowing that.”

Respecting the cultural differences is also key, especially when it comes to religious differences that dictate much of a person’s life decisions.

Spector wrote that many problems arise when the care provider adheres rigidly to the Western system of health care, while a patient from another culture may hold completely different beliefs. She recommends that providers explore alternative ideas about health and “adjust their approach to coincide with the needs of a specific patient.”

Otherwise, communication can break down, and the patient might not receive good care.

“If you want to care for a Muslim…people have to understand their way of life is Islam,” ElGindy said. “You cannot understand unless you understand their religion because it is a way of life.”

For example, ElGindy said, Muslims fast from sunrise to sunset during ther holy month of Ramadan, which usually begins in November. If a nurse practitioner or doctor prescribes a drug that must be taken four times per day to a Muslim patient during Ramadan, the patient may be very reluctant to accept the prescription.

“He is not qualified to ask me to break the fast,” ElGindy said, adding that she would have to consult an Islamic scholar for advice if the provider were not acquainted with the customs and requirements of Islam.

Culturally sensitive care would have the health care provider prescribing a drug that could be taken only twice a day, once before dawn and once after sunset. Islam does allow exceptions to the fast rules for the elderly or lactating women, but someone unfamiliar with the religion and culture might not know that.

“It needs a lot of understanding,” ElGindy said. “People are not willing to violate their religious rules and regulations.”

A knowledge of acceptable foods can also be vital to providing culturally sensitive care.

Many Asian cultures have concepts of “hot” and “cold” foods as appropriate treatments for specific conditions, Scott said. According to Spector, some Hispanic cultures also have acceptable “hot” and “cold” remedies for certain ailments.

For instance, chicken and raisins are “cold” foods in the Puerto Rican community in New York. A woman who has just delivered a baby is encouraged to avoid “cold” foods in favor of “hot” foods, like corn meal or garlic.

Williams and ElGindy are adamant that educating the health care field to incorporate an awareness of cultural differences when providing health care is a step in the right direction.

“The only way to get around it is education,” Williams said. “It’s a matter of people bringing these things up.”

Dec. 28, 2001. © 2002. NurseZone.com. All Rights Reserved.